Life After 50 Expo

SAD explained!

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Seasonal affective disorder (SAD) is a type of depression related to changes in seasons. For most, people with SAD feel symptoms begin in late fall or early winter and affect their energy, mood, and behavior through the end of winter. With fewer hours of sunlight and less socializing with others right now, SAD symptoms may affect many of us this winter. Rather than brush off the “winter blues,” recognize that you are not alone and that you can take steps to steady your mood throughout the year. Lifestyle and home changes (such as making your environment sunnier, getting outside, and exercising) can alleviate milder SAD symptoms. And while it’s normal to have some days where you feel down, you should see your doctor if you feel down for days at a time or you can’t get motivated to do activities you normally enjoy. To read more about SAD symptoms and treatments, visit Mayo Clinic. For 24/7 treatment referral and information, contact the SAMHSA National Helpline at 800-662-HELP (4357).

 
 

Dear Marci,

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Dear Marci,

I have been an inpatient at a hospital for a week, and I just received a notice that Medicare will no longer pay for my stay. I will be discharged from the hospital in two days, but I don’t think I have recovered enough to leave yet. How can I appeal my discharge from a hospital?

– Ruby (South Bend, IN)

Dear Ruby,

If you are receiving care in a hospital and are told that your Medicare will no longer pay for your care (and you will be discharged), you have the right to file a fast appeal if you do not believe your care should end.

If you are a hospital inpatient, you should receive a notice titled Important Message from Medicare within two days of being admitted. This notice explains your patient rights, and you will be asked to sign it. If your inpatient hospital stay lasts three days or longer, you should receive another copy of the same notice up to two days, and no later than four hours, before you are discharged. 

If you think you are being discharged too soon, follow instructions on the Important Message from Medicare to file an expedited appeal to the Quality Improvement Organization (QIO). Contact the QIO by midnight of the day of your discharge. 

Once you file the appeal, the hospital must give you a Detailed Notice of Discharge, which explains in writing why your hospital care is ending. The QIO should call you with its decision within 24 hours of receiving all the information it needs. 

If the QIO decides your care should end, you will be responsible for paying for any care you receive after noon of the day after the QIO makes its decision. If your appeal to the QIO is successful, your care will continue to be covered.

If your appeal is denied at this first level, you can continue to appeal by following instructions on the denial notices you receive. There are five levels of appeal in total; the timing and agency involved depend on whether you have Original Medicare or a Medicare Advantage Plan. You have the right to continue appealing if you are not successful. If you are unable to appeal, a family member or other representative can appeal for you. 

Expedited appeals have tight deadlines, so it is important to pay attention to the timeframes for appealing at each level. Keep copies of any appeal paperwork you send out, and if you speak to someone on the phone, get their name and write down the date and time that you spoke to them. It is helpful to have all of your appeal documents together in case you run into any problems and need to access documents you already mailed. 

– Marci
 

Dear Marci,

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Dear Marci,

I have been receiving outpatient physical therapy for a while now, and my condition is not improving. I am worried about reaching a therapy cap or losing coverage for not meeting an improvement standard. How can I troubleshoot potential coverage issues with my physical therapist?

-Venita (Mobile, AL) 

Dear Venita,

Medicare Part B covers outpatient therapy, including physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT). Previously, there was a limit, known as the therapy cap, on how much outpatient therapy Original Medicare covered annually. However, in 2018, the therapy cap was removed.

If your total therapy costs reach a certain amount, Medicare requires your provider to confirm that your therapy is medically necessary. This is not a therapy cap, but it does require your provider to take action before Medicare will cover continued care.

In 2020, Original Medicare covers up to:

  • $2,080 for PT and SPL before requiring your provider to indicate that your care is medically necessary .
  • And, $2,080 for OT before requiring your provider to indicate that your care is medically necessary.

If your provider has questions about how to bill Medicare for more therapy, let them know they should contact the Medicare Administrative Contractor (MAC) for their state.

Medicare pays for up to 80% of the Medicare-approved amount. This means Original Medicare covers up to $1,664 (80% of $2,080) before your provider is required to confirm that your outpatient therapy services are medically necessary. If Medicare denies coverage because it finds your care is not medically necessary, you can appeal.

It is also important to know that Medicare will cover your physical therapy even if your condition is not improving. Medicare covers skilled nursing facility, home health, and outpatient therapy careregardless of whether your condition is temporary or chronic, or whether your condition is improving or not, as long as the care is medically necessary for another reason. This was clarified in the settlement of a class action lawsuit, Jimmo v. Sebelius. The settlement agreement explained that an improvement standard cannot be the only test applied when Medicare is determining coverage of claims that require skilled care, such as skilled therapy. Medicare covers services that are needed to: 

  • Help maintain ability to function
  • Help regain or improve your function
  • Prevent or slow the worsening of your condition

In other words, your coverage of skilled therapy cannot end solely because your condition is not improving. If your therapy is being denied or ending just because you are not improving, you should file an appeal.

-Marci

Dear Marci,

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Dear Marci,

I have been struggling with back pain. My doctor prescribed me physical therapy, but I am not sure what coverage or costs I should expect. How does Medicare cover outpatient skilled therapy?

– Cameron (Bangor, ME)

Dear Cameron,

Skilled therapy services are services from licensed therapists or skilled therapy providers. There are three main types of skilled therapy covered by Medicare:

  • Physical therapy (PT): Exercise and physical activities used to condition muscles and improve levels of activity. It is helpful for those with physically debilitating illness. PT will help you regain movement and strength in a body area.
  • Speech/language pathology (SLP): Therapeutic treatment of speech impairments (such as lisping and stuttering) or speech difficulties that result from illness. SLP will help you regain and strengthen speech and language skills.
  • Occupational therapy (OT): Therapy using meaningful activities of daily living to assist people who have difficulty acquiring or performing meaningful work due to impairment or limitation of physical or mental function. OT helps you regain the ability to do usual daily activities by yourself such as eating and putting on clothes.

People commonly get skilled therapy on an outpatient basis. Medicare Part B will cover skilled therapy when received as an outpatient (not formally admitted to a hospital or skilled nursing facility). You can get therapy services in a doctor’s office, outpatient hospital setting, rehabilitation agency, Comprehensive Outpatient Rehabilitation Facility (CORF), public health agency, or your home (if your home health care is covered by Part B). You are eligible for Medicare coverage of outpatient therapy services if:

  • You need skilled therapy services, and the services are considered safe and effective treatment for you
  • Your doctor or therapist creates a plan of care before you start receiving services
  • Your doctor or therapist regularly reviews the plan of care and makes changes as needed

If you meet Medicare’s eligibility requirements, Medicare covers therapy on a temporary basis to improve or restore your ability to function, or on an ongoing basis to prevent you from getting worse. Medicare should cover your outpatient therapy regardless of whether your condition is temporary or chronic.

Original Medicare covers outpatient therapy at 80% of the Medicare-approved amount and you may pay a 20% coinsurance after you meet your Part B deductible ($198 in 2020). There is no cap for how much outpatient therapy Medicare covers each year. However, once you reach $2,080 in total therapy costs in 2020, Medicare requires your provider to confirm that your therapy is medically necessary. If you are in a Medicare Advantage Plan, your costs may differ. You should contact your plan directly to find out what your estimated costs may be.

– Marci

Dear Marci,

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Dear Marci,

I hear that I can change my Part D prescription drug coverage this fall if I would like. My Part D plan has worked fine for me this past year, but I still want to look at my other options. How do I use the Medicare.gov Plan Finder tool to compare Part D plans?

– Grace (Richmond, VA)

Dear Grace,

Yes, it is true that you can make changes to your coverage, including your Part D plan, during Fall Open Enrollment, which spans October 15 through December 7 of each year. Changes made during Fall Open Enrollment will be effective January 1 of the following year. Part D plans may change their costs and formularies (list of covered drugs) from year-to-year, so it is important to review your current plan and Annual Notice of Change to learn if your premium, deductible, or cost-sharing will change and whether your drugs will still be covered next year.  

Medicare Plan Finder is an online tool at www.medicare.gov that can be used to compare stand-alone Part D plans or Medicare Advantage Plans. Plan Finder provides information about costs, which drugs are included on the plan’s formulary, and the star rating of the plan.

To use Plan Finder, follow these steps:

  • Go to www.medicare.gov and click on the button that says “Find 2021 Health and Drug Plans.”
  • You can do a general search by clicking the “Continue Without Logging In” button. If you wish to save your results and information, you can log in using your MyMedicare account.
  • Next, you can choose whether you are looking for a Medicare Advantage or Part D plan and enter your zip code.
  • Then you can enter the drugs you take, choose the pharmacies you use, and indicate whether you are interested in a mail order option.

Plan Finder will display results for plans in your area. Note that a plan may not cover all of the drugs you take, but it may have alternatives on its formulary. Speak to your provider about whether these alternatives would be appropriate for you. Plan Finder also tells you if the plan has a deductible and how much the monthly premium is.

Initially, the plans will be sorted by “lowest drug + premium costs.” This is the closest estimate to what you may pay out of pocket for your Part D coverage for the year. You can select “Plan Details” to find out more specifics about coverage, including any coverage restrictions that might apply to your drugs.

Before enrolling, it is a good idea to call the plan directly to confirm any information you read on Plan Finder, as information may not be completely up-to-date. You can enroll in a plan online, by calling 1-800-MEDICARE, or by calling the plan directly.

You can make as many changes as you want between October 15 and December 7, but only the last change you make will take effect on January 1. If you choose a plan and realize that it is the wrong plan after Fall Open Enrollment is over, in most cases you will not be able to change your coverage until the next Fall Open Enrollment Period. For this reason, it is important to carefully consider all of your options and take the time to research each plan in order to make a decision that fits your health care needs.

– Marci